Each year, approximately 8 million adverse incidents occur among vulnerable nursing home (NH) residents. An adverse incident is defined as "unplanned events [unreadable] which caused, or had the potential to cause, harm to patients." There are a variety of adverse incidents that occur in the NH setting including falls; adverse drug events or medication errors; resident altercations or other types of abuse; and non-fall related injuries such as burns, skin tears, or bruises. Depending on their severity, the occurrence of these incidents can lead to significant morbidity and mortality and subsequently result in considerable NH staff time and increased costs to care for them." [unreadable] [unreadable] Clearly, these incidents represent a significant problem in NHs. One start to reducing adverse incidents is to use reporting systems. The Institute of Medicine Reports call for enhancements in adverse incident reporting. Improvements in reporting practices is significant because incident reporting systems have been used successfully in other disciples such as aviation safety to significantly augment safety initiatives. Investigating the circumstances surrounding an adverse incident is important to improve prevention and intervention efforts and use of incident reporting systems is aimed at improving health care processes through the analysis of data. This process requires standardized definitions of the incident, data elements, and approaches for collecting and integrating the data. [unreadable] [unreadable] Further research is necessary on the current practice of how incidents are evaluated in nursing homes. Moreover, in order to improve how incidents are reported and analyzed for quality improvement, the role Health Information Technology (HIT) plays in this endeavor should be investigated. The purpose of this study is to examine the incident reporting practices in NHs and identify to what extent these data are used for improving the safety of residents. Ultimately, this research is expected to increase the knowledge base that will assist researchers to improve the workflow design of adverse incident evaluation and the role HIT and health care policy development plays in this. This information will further our development of a standardized incident reporting mechanism recommended by the Institute of Medicine and others. [unreadable] [unreadable] [unreadable]